Tracheal Hemangioma: The "Cherry" in the Trachea.

A young adult presented with a four-month long history of hemoptysis. A computed tomography (CT) scan showed a mid-trachea lesion (Figure 1). A flexible bronchoscopy was performed and revealed a cherry-like polyp (Figure 2(a)) and biopsy resulted in brisk bleeding. The polyp was coagulated at the base with a Nd-YAG (neodymium doped-yttrium aluminium garnet) laser followed by forceps resection via the rigid bronchoscope (Video). Histology of the 8 mm by 10 mm lesion was classic of a lobular capillary hemangioma (LCH) (Figure 3). The patient had been asymptomatic since and bronchoscopy performed two years later showed no tumor recurrence (Figure 2(b)).

Figure 1

Computed tomography showed a homogeneously contrast enhanced polyp (white arrow) on the left lateral wall of the mid-trachea.

Figure 2

(a) Distinct cherry-like polyp consistent with hemangioma arising from the left lateral wall of the mid-trachea depicted on bronchoscopy. (b) Bronchoscopy performed two years later revealed a small scar induration with normal mucosa (arrow) overlaying it at the base of the previously resected hemangioma.

Figure 3

A nodular lesion with squamous metaplasia (marked downwards thick arrow) of the surface epithelium, underlying fibrinous exudates (marked ∗), and a florid proliferation of small capillaries (marked →) surrounded by fibrous stroma on 10x Hematoxylin and Eosin section.

Lobular capillary hemangioma (LCH) is typically found on cutaneous and oronasal mucosa. Tracheobronchial LCH is a rarity [1]. Hemoptysis often occurs for a short duration ranging from weeks to months with the exception of one reported case of massive hemoptysis which required arterial embolization. The airway lesion is usually small (<10 mm), sessile, or polypoid with a distinctive glinting vascular (cherry) appearance that bleeds easily. Pathogenesis of this benign tumor is unclear and has been correlated to infections, trauma, and hormonal shifts [1]. The latter can be supported by the case of a rapidly growing trachea LCH (40 mm by 20 mm) found in a pregnant lady who presented with critical airway obstruction [2]. The characteristic findings of a homogeneously contrast enhanced lesion seen on CT scan and an airway lesion (as described above) observed during bronchoscopy should lead to a cautious biopsy to clinch the diagnosis.

Bronchoscopic ablative intervention often results in a cure although past reports had a follow-up of one year or less. Ablative modalities included endoscopic resection with Nd-YAG laser, argon plasma coagulation, electrocautery, cryotherapy, and forceps. In one reported case of tumor recurrence, brachytherapy was applied.